REV14222

• Permit No: M1982112
• IBM Index Class Name: Revision
• Type & Sequence: HR1
• Media Type: D
• Archive: No

-- AIR POLLUTION COL DIVISION - COLORADO DEPARTM OF HEALTH
• 4210 East 11th A~.Rfue, Denver, Colorado 80220-Pho~ 320-4180
APPLICATION FOR EMISSION PERMIT
This application shall be filled out completely - see instructions on reverse side.
1. PERMIT TO BE ISSUED T0:
Telephone No.i•gq~_3~ -jj)
2. MAILING ADDRESS (include ZIP Code): ~ o• Sox lion A~+aoa Co goo of
3. TYPE OF ORGANIZATION:
Corporation ~ Partnership ~ Individual Owner ^,' Governmental Agency
4. AGENT FOR SERVICE: 1
i
4a~/ l3La~9 1[P PAL/Sp,;: ( rE.~,~~ Svbs~d,gQy)
' S. GENERAL NATURE OF BUSINESS: (Include SIC Code if known)
Asph,aGT /~(•oG/ucTioN
6. AIR POLLUTION SOURCE: Pursuant to Regulation No. 3 of the Colorado Air Quality
Control Commission, application is hereby made for an
~ Emission Permit for the following air pollution source
! (attach separate sheet where necessary);
7. SOURCE LOCATION ADDRESS: (Include UTM Coordinates if known)
COUNTY (I ES) : E/ART
8. ESTIMATED COST OF SOURCE OR MODIFICATIONS: Process
Air Pollu~t(ion SControl Equipmennt~D,G~o Equipment~j~.~~p
(Note: Appl i~a~so^ewil5ano2o~iecconslldebed-peratjed ~onya,s :P
Como a rovfdina information reouested:
~ 9. STATUS (check and complete applicable items):
New Air Pollutant Source Estimated Date Estimated Date
Control Equipment Being Construction Construction Will
0 Added to Existing Source Will Begin: Be Completed:
Activity Change ~~-;I~,iaP3 ,ry'fg.~(1/5A3
i
I 10. Check is enclosed to cover AP EN FILING FEE: $40.00 PER APEN
I (See No. 10 on reverse side of this form)
11. ANTICIPATED START-UP DATE 12. DATE OF APPLICATION
~'la~ 9, /ss73 7~e 17 ~9h3
13• SrGNATURE OF XE~LY~IJTHOgl~ PERSON
14. Type or print na and officia
~. ~/roy ,/~//1Vy lJrLC. vices-/rv.o~v
Date Received 15• REMARKS:
APCD 2000 (REV.
e of person signing this application.